Article

Patient Concerns About Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery

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Abstract

Purpose Wide-Awake Local Anesthetic No Tourniquet (WALANT) hand surgery avoids many medical risks associated with traditional anesthesia options. However, patients may be hesitant to choose the WALANT approach because of concerns about being awake during surgery. The purpose of this study was to characterize patients’ thoughts and concerns about being awake during hand surgery and determine factors that may affect their decision about anesthesia options. Methods Qualitative interviews were conducted with 15 patients with a diagnosis of carpal tunnel syndrome, trigger finger, or De Quervain’s tenosynovitis who were receiving nonoperative care. Interviews were conducted using a semi-structured interview guide. Inductive thematic analysis was used to identify themes, concerns, and potential intervention targets. Results Eight participants reported that patients have a general bias against being “knocked out,” 7 of whom described concerns of uncertainty about emerging from anesthesia. All participants would consider WALANT, with some reservations. Recurrent themes included ensuring they would not feel, see, or hear the surgery and a preference toward distractions, such as music or engaging conversation. Of 15 participants, 13 would not want to see the surgery. For patients who found WALANT appealing, they valued the decreased time investment compared to sedation and the avoidance of side effects or exacerbation of comorbidities. A recurring theme of trust between surgeon and patient arose when deciding about anesthesia type. Conclusions Most patients are open to WALANT, but have concerns of hearing the surgery or feeling pain. Potential interventions to address these concerns, beyond establishing a trusting physician-patient relationship, include music or video with headphones and confirming skin numbness prior to surgery. Clinical relevance This study provides insights into patients’ thought processes regarding WALANT hand surgery and give the surgeon talking points when counseling patients on their anesthesia type for hand surgery.

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... As Morris et al. showed, WALANT offers a solution for patients who are fearful of general anesthesia and its side effects. With regard to WALANT specifically, patients were most concerned with hearing or seeing the procedure as it was being performed and the possibility of feeling pain intraoperatively [67]. Furthermore, Lee et al. found that anxiety was higher among WALANT patients when compared with patients who were given local anesthesia with a tourniquet, although there was no change in overall satisfaction [68]. ...
... First, it is essential that patients are comfortable with the idea of remaining awake during surgery. As discussed, there are multiple concerns and anxieties that may interfere with the safe execution of CTR under WALANT [67]. It is critical for surgeons to appropriately manage expectations in patients prior to WALANT procedures, as patients with certain comorbidities or low thresholds of anxiety may be better suited to alternative anesthesia methods. ...
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As surgical management of carpal tunnel release (CTR) becomes ever more common, extensive research has emerged to optimize the contextualization of this procedure. In particular, CTR under the wide-awake, local-anesthesia, no-tourniquet (WALANT) technique has emerged as a cost-effective, safe, and straightforward option for the millions who undergo this procedure worldwide. CTR under WALANT is associated with considerable cost savings and workflow efficiencies; it can be safely and effectively executed in an outpatient clinic under field sterility with less use of resources and production of waste, and it has consistently demonstrated standard or better post-operative pain control and satisfaction among patients. In this review of the literature, we describe the current findings on CTR using the WALANT technique.
... A clinical trial comparing distal radius plating surgery using WALANT and GA showed that those treated by the WALANT technique had no difference in perioperative anxiety level and intraoperative visual analog scale for pain (VAS) [15]. Although hand surgery via the WALANT technique showed tolerable pain and optimal outcomes, patients still have concerns about feeling pain [18]. As a result, more evidence is needed to confirm the detailed intraoperative physiological changes and pain scale of patients who underwent surgery using the WALANT technique. ...
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This prospective case-control study aimed to compare the intraoperative hemodynamic changes between the wide-awake local anesthesia no tourniquet (WALANT) technique and general anesthesia (GA) in patients undergoing distal radius plating surgery. Forty adults with distal radius fractures underwent plating surgery via the WALANT technique (20 patients) or GA (20 patients). Mean arterial pressure (MAP) and heart rate were recorded. Intraoperative pain intensity was measured using the visual analog scale (VAS) for pain in the WALANT group. The measures of hemodynamics and VAS were recorded at seven-time points perioperatively. The VAS score decreased significantly compared with the preoperative status in the WALANT group for most of the intraoperative period except during injections of local anesthetics and fracture reduction. The intraoperative MAP in the WALANT group showed no significant change during the perioperative period. In addition, the WALANT group showed fewer perioperative MAP fluctuations than the GA group (p < 0.05). The reduction and plating quality were similar between the two groups. WALANT provided a feasible technique with less fluctuation in hemodynamic status. With gentle manipulation of the fracture reduction, distal radius plating surgery using the WALANT technique is a well-tolerated surgical procedure and shows similar reduction and plating quality to GA.
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Introduction: Available short-acting intrathecal anesthetic agents (chloroprocaine and prilocaine) offer an alternative to general anesthesia for short-duration surgical procedures, especially ambulatory surgeries. Factors determining the choice of anesthesia for short-duration procedures have not been previously identified. Methods: This observational, prospective, multicenter, cohort study was conducted between July 2015 and July 2016, in 33 private or public hospitals performing ambulatory surgery. The primary objective was to determine the factors influencing the choice of anesthetic technique (spinal or general anesthesia). Secondary outcomes included efficacy of the anesthesia, time to hospital discharge, and patient satisfaction. Results: Among 592 patients enrolled, 309 received spinal anesthesia and 283 underwent general anesthesia. In both study arms, the most frequently performed surgical procedures were orthopedic and urologic (43.3% and 30.7%, respectively); 66.1% of patients were free to choose their type of anesthesia, 21.8% chose one of the techniques because they were afraid of the other, 16.8% based their choice on the expected ease of recovery, 19.2% considered their degree of anxiety/stress, and 16.9% chose the technique on the basis of its efficacy. The median times to micturition and to unassisted ambulation were significantly shorter in the general anesthesia arm compared with the spinal anesthesia arm (225.5 [98; 560] min vs. 259.0 [109; 789] min; p = 0.0011 and 215.0 [30; 545] min vs. 240.0 [40; 1420]; p = 0.0115, respectively). The median time to hospital discharge was equivalent in both study arms. In the spinal anesthesia arm, patients who received chloroprocaine and prilocaine recovered faster than patients who received bupivacaine. The time to ambulation and the time to hospital discharge were shorter (p < 0.001). The overall success rate of spinal anesthesia was 91.6%, and no significant difference was observed between chloroprocaine, prilocaine, and bupivacaine. The patients' global satisfaction with anesthesia and surgery was over 90% in both study arms. Conclusions: Patient's choice, patient fear of the alternative technique, patient stress/anxiety, the expected ease of recovery, and the efficacy of the technique were identified as the main factors influencing patient choice of short-acting local anesthesia or general anesthesia. Spinal anesthesia with short-acting local anesthetics was preferred to general anesthesia in ambulatory surgeries and was associated with a high degree of patient satisfaction. Trial registration: ClinicalTrials.gov identifier NCT02529501. Registered on June 23, 2015. Date of enrollment of the first participant July 21, 2015.
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Background: Trigger finger release utilizing wide-awake local anesthesia no tourniquet (WALANT) usage in extremity surgery is not widely used in our setting due to the possibility of necrosis. Usage of a tourniquet is generally acceptable for providing surgical field hemostasis. We evaluate hemostasis score, surgical field visibility, onset and duration of anesthesia, pain score, and the duration of surgery and potential side effects of WALANT. Methods: Eighty-six patients scheduled for trigger finger release between July 2016 and December 2017 were randomized into a control group (1% lignocaine and 8.4% sodium bicarbonate with arm tourniquet; given 10 min prior to procedure) and an intervention group (1% lignocaine, 1:100,000 of adrenaline and 8.4% sodium bicarbonate; given 30 min prior to procedure), with a total of 4 ml of solution injected around the A1 pulley. The onset of anesthesia and pain score upon injection of the first 1 ml were recorded. After the procedure, the surgeon rated for the hemostasis score (1-10: 1 as no bleeding and 10 being profuse bleeding). Duration of surgery and return of sensation were recorded. Results: Hemostasis score was grouped into visibility score as 1-3: good, 4-6: moderate, and 7-10: poor. The intervention group (with adrenaline) had a 74% of good surgical field visibility compared to 44% from the controlled group (without adrenaline; p < 0.05). Duration of anesthesia was longer in the intervention group (with adrenaline), with a 2.77-h difference. Conclusion: WALANT provides excellent surgical field visibility and is safe and on par with conventional methods but without the usage of a tourniquet and its associated discomfort.
Article
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Objective The use of wide-awake local anesthesia with no tourniquet (WALANT) is becoming an excellent alternative for elective hand surgeries and hand surgeries involving minor trauma. Although the use of WALANT for some soft tissue surgeries has become the state of the art, data regarding bony procedures, such as fracture management, under WALANT are limited. This study was performed to assess the WALANT technique for open reduction and internal fixation of distal radius fractures. Methods Five patients with displaced distal radius fractures were enrolled in the study. WALANT was carried out about 30 minutes prior to the first incision. Surgery was performed in the normal fashion, and the fractures were fixed using anatomic locking plates. After surgery, the patients were admitted overnight for observation and pain assessment, and they were discharged within 24 hours postoperatively. Intraoperative and postoperative complications were recorded. Follow-up was performed in our outpatient clinic. No abnormalities were recorded. Results All patients underwent a successful painless surgery. No extra bleeding or other complications were recorded. Conclusion The WALANT technique offers a simple and safe alternative to traditional anesthetic techniques for open reduction and plating of distal radius fractures.
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Book
Most writing on sociological method has been concerned with how accurate facts can be obtained and how theory can thereby be more rigorously tested. In The Discovery of Grounded Theory, Barney Glaser and Anselm Strauss address the equally Important enterprise of how the discovery of theory from data-systematically obtained and analyzed in social research-can be furthered. The discovery of theory from data-grounded theory-is a major task confronting sociology, for such a theory fits empirical situations, and is understandable to sociologists and laymen alike. Most important, it provides relevant predictions, explanations, interpretations, and applications. In Part I of the book, "Generation Theory by Comparative Analysis," the authors present a strategy whereby sociologists can facilitate the discovery of grounded theory, both substantive and formal. This strategy involves the systematic choice and study of several comparison groups. In Part II, The Flexible Use of Data," the generation of theory from qualitative, especially documentary, and quantitative data Is considered. In Part III, "Implications of Grounded Theory," Glaser and Strauss examine the credibility of grounded theory. The Discovery of Grounded Theory is directed toward improving social scientists' capacity for generating theory that will be relevant to their research. While aimed primarily at sociologists, it will be useful to anyone Interested In studying social phenomena-political, educational, economic, industrial- especially If their studies are based on qualitative data. © 1999 by Barney G. Glaser and Frances Strauss. All rights reserved.
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Purpose: Carpal tunnel syndrome is a common disease treated operatively. During the operation, the patient may be wide-awake or sedated. The current literature has only compared separate cohorts. We sought to compare patient experience with both local-only anesthesia and sedation. Methods: Staged bilateral carpal tunnel release utilizing open or endoscopic technique was scheduled and followed through to completion of per-protocol analysis in 31 patients. Patients chose initial hand laterality and were randomized regarding initial anesthesia method: local-only or sedation. Data collection via questionnaires began at consent and continued to 6 weeks postoperatively from second procedure. Primary outcome measures included patient satisfaction and patient anesthesia preference. Results: At final follow-up, 6 weeks postoperatively, high satisfaction (30 of 31 patients per method) was reported with both types of anesthesia. Among these patients, 17 (54%) preferred local-only anesthesia, 10 (34%) preferred sedation, 2 had no preference, and 2 opted out of response. Although anesthesia fees were approximately $390 lower with local-only anesthesia, total costs for carpal tunnel release were not significantly different with respect to the anesthesia cohorts. Total time in surgical facility was approximately 26 minutes quicker with local-only anesthesia, largely due to shorter time in the post-anesthesia care unit. Scaled comparison of worst postoperative pain following the 2 procedures revealed no difference between local-only anesthesia and sedation. Conclusions: Patients reported equal satisfaction scores with carpal tunnel release whether performed under local-only anesthesia or with sedation. In addition, local-only anesthesia was indicated as the preference of patients in 59% of cases.
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Background: Hand surgery under local anesthesia only has been utilized more frequently in recent years. The purpose of this study was to compare perioperative time and cost for carpal tunnel release (CTR) performed under local anesthesia (WALANT) only to those performed under intravenous sedation (MAC). Methods: A retrospective comparison of intra-operative (OR) surgical time and post-operative (PACU) time for consecutive CTR procedures performed under both MAC and WALANT was undertaken. All operations were performed by the same surgeon using the same mini-open surgical technique. A cost analysis was performed via standardized anesthesia billing based on base units, time, and conversion rates. Results: There were no significant differences between the two groups in terms of total OR time, 28 minutes in the MAC group versus 26 minutes in the WALANT group. PACU times were significantly longer in the MAC group (84 minutes) compared to the WALANT group (7 minutes). Depending on conversion rates used, a total of $139-$432 was saved in each case done with WALANT by not using anesthesia services. In addition, a range of $1,320-$1,613 was saved for the full episode of care including anesthesia costs, OR time, and PACU time for each patient undergoing WALANT CTR. Conclusions: CTR surgery performed with the WALANT technique offers significant reduction in cost utilization of anesthesia and PACU resources.
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Background Carpal tunnel release (CTR) is the most common surgery of the hand, and interest is growing in performing it under local anesthesia without tourniquet. To better understand differences, we hypothesized that patients undergoing CTR under wide-awake local anesthesia with no tourniquet (WALANT) versus sedation (monitored anesthesia care [MAC]) would not result in a difference in outcome. Methods Consecutive cases of electrodiagnostically confirmed open CTR across multiple surgeons at a single center were prospectively enrolled. Data included demographic data, visual analog scale, Levine-Katz carpal tunnel syndrome scale, QuickDASH questionnaire, customized Likert questionnaire, and complications. Results There were 81 patients enrolled in the WALANT group and 149 patients in the MAC group. There were no reoperations in either group or any epinephrine-related complications in the WALANT group. Disability and symptom scores did not differ significantly between WALANT and sedation groups at 2 weeks or 3 months. Average postoperative QuickDASH, Levine-Katz, and VAS pain scales were the same in both groups. Both groups of patients reported high levels of satisfaction at 91 versus 96% for the WALANT versus MAC groups, respectively (p > 0.05). Patients in each group were likely to request similar anesthesia if they were to undergo surgery again. Conclusion Patients undergoing open CTR experienced similar levels of satisfaction and outcomes with either the WALANT or MAC techniques. There was no statistically significant difference between either group relative to the tested outcome measures. These data should facilitate surgeons and patients' choosing freely between WALANT and MAC techniques relative to complications and outcomes.
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Background: There has been recent interest in wide awake hand surgery, also referred to as "wide awake local anesthesia with no tourniquet" (WALANT) surgery. Using a model of single trigger finger release (TFR) surgery, a hypothesis was made that WALANT would result in decreased hospital time and cost than patients receiving sedation with monitored anesthetic care (MAC). Methods: Consecutive cases of single TFR surgery with MAC were compared with WALANT. All surgeries were performed in the same manner, at the same facility, and by the same surgeon. Total operating room (OR) time, surgical time, recovery time, and anesthesia costs were analyzed. Results: There were 78 patients: 31 MAC and 47 WALANT. The MAC group averaged 27.2 minutes of OR time; the WALANT group averaged 25.2 minutes. The MAC group surgical time was 10.2 minutes versus WALANT of 10.4 minutes. Post-operatively, the MAC group averaged 72.3 minutes in the recovery room compared with WALANT group of 30.2 minutes. Each case performed under MAC had a minimum of excess charges from anesthesia of approximately $105. Conclusions: Patients undergoing single TFR surgery under WALANT trended toward less time in the OR, had similar surgical times, and spent significantly less time in the recovery room, compared with MAC, thereby resulting in less indirect costs. Each MAC case also had minimum direct excess anesthesia charges of $105, which knowingly underestimates overall charges as it excludes material and fixed costs associated with the delivery of anesthesia. Avoiding sedation for high-volume procedures such as TFR may result in significant systemic savings to payers, and in the future with bundling and episode-based payments can become increasingly important to patients, facilities, and surgeons.
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Evaluators often use qualitative research methods, yet there is little evidence on the comparative cost-effectiveness of the two most commonly employed qualitative methods—in-depth interviews (IDIs) and focus groups (FGs). We performed an inductive thematic analysis of data from 40 IDIs and 40 FGs on the health-seeking behaviors of African American men (N = 350) in Durham, North Carolina. We used a bootstrap simulation to generate 10,000 random samples from each data set and calculated the number of data collection events necessary to reach different levels of thematic saturation. The median number of data collection events required to reach 80% and 90% saturation was 8 and 16, respectively, for IDIs and 3 and 5 for FGs. Interviews took longer but were more cost-effective at both levels. At the median, IDIs cost 20–36% less to reach thematic saturation. Evaluators can consider these empirically based cost-effectiveness data when selecting a qualitative data collection method.
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Purpose: This study described physical and psychosocial limitations associated with adult brachial plexus injuries (BPI) and patients' expectations of BPI surgery. Methods: During in-person interviews, preoperative patients were asked about expectations of surgery and preoperative and postoperative patients were asked about limitations due to BPI. Postoperative patients also rated improvement in condition after surgery. Data were analyzed with qualitative and quantitative techniques. Results: Ten preoperative and 13 postoperative patients were interviewed; mean age was 37 years, 19 were men, all were employed/students, and most injuries were due to trauma. Preoperative patients cited several main expectations, including pain-related issues, and improvement in arm movement, self-care, family interactions, and global life function. Work-related expectations were tailored to employment type. Preoperative and postoperative patients reported that pain, altered sensation, difficulty managing self-care, becoming physically and financially dependent, and disability in work/school were major issues. All patients reported making major compensations, particularly using the uninjured arm. Most reported multiple mental health effects, were distressed with long recovery times, were self-conscious about appearance, and avoided public situations. Additional stresses were finding and paying for BPI surgery. Some reported BPI impacted overall physical health, life priorities, and decision-making processes. Four postoperative patients reported hardly any improvement, four reported some/a good deal, and five reported a great deal of improvement. Conclusions: BPI is a life-altering event affecting physical function, mental well-being, financial situation, relationships, self-image, and plans for the future. This study contributes to clinical practice by highlighting topics to address to provide comprehensive BPI patient-centered care.
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Purpose: This study tested the null hypothesis that there are no differences between the preferences of hand surgeons and those patients with carpal tunnel syndrome (CTS) facing decisions about management of CTS (ie, the preferred content of a decision aid). Methods: One hundred three hand surgeons of the Science of Variation Group and 79 patients with CTS completed a survey about their priorities and preferences in decision making regarding the management of CTS. The questionnaire was structured according the Ottawa Decision Support Framework for the development of a decision aid. Results: Important areas on which patient and hand surgeon interests differed included a preference for nonpainful, nonoperative treatment and confirmation of the diagnosis with electrodiagnostic testing. For patients, the main disadvantage of nonoperative treatment was that it was likely to be only palliative and temporary. Patients preferred, on average, to take the lead in decision making, whereas physicians preferred shared decision making. Patients and physicians agreed on the value of support from family and other physicians in the decision-making process. Conclusions: There were some differences between patient and surgeon priorities and preferences regarding decision making for CTS, particularly the risks and benefits of diagnostic and therapeutic procedures. Clinical relevance: Information that helps inform patients of their options based on current best evidence might help patients understand their own preferences and values, reduce decisional conflict, limit surgeon-to-surgeon variations, and improve health.
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Some patients with a functionally impaired lower limb choose to have an elective amputation, whereas others do not. Functional outcomes do not favor either type of treatment, making this a complex decision. The experiences of patients who have chosen elective amputation were analyzed to identify the key factors in this decision-making process. Patients from a tertiary care amputee clinic who had chosen to undergo elective amputation of a functionally impaired lower limb participated in the present study. A qualitative research design involved the use of one-on-one semi-structured interviews, which were audio recorded and transcribed. Narrative analysis was used by three researchers to provide triangulation. Recurrent key themes and patterns were described. Personal factors in the decision-making process were identified. Factors that had the largest impact on the decision-making process were pain, function, and participation. Body image, self identity, and the opinions of others had little influence. Satisfaction with the surgical outcome was related to how closely the result matched the patient's expectations. Patients who were better informed prior to surgery had more realistic expectations about living with an amputation. The severity of pain and the desire for improved function are strong drivers for patients deciding to undergo elective amputation of a functionally impaired lower extremity. While patients do not want others' opinions, information regarding life with an amputation helps to set realistic expectations regarding outcome.
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Qualitative research is a useful approach to explore perplexing or complicated clinical situations. Since 1996, at least fifteen qualitative studies in the area of total knee replacement alone were found. Qualitative studies overcome the limits of quantitative work because they can explicate deeper meaning and complexity associated with questions such as why patients decline joint replacement surgery, why they do not adhere to pain medication and exercise regimens, how they manage in the postoperative period, and why providers do not always provide evidence-based care. In this paper, we review the role of qualitative methods in orthopaedic research, using knee osteoarthritis as an illustrative example. Qualitative research questions tend to be inductive, and the stance of the investigator is relevant and explicitly acknowledged. Qualitative methodologies include grounded theory, phenomenology, and ethnography and involve gathering opinions and text from individuals or focus groups. The methods are rigorous and take training and time to apply. Analysis of the textual data typically proceeds with the identification, coding, and categorization of patterns in the data for the purpose of generating concepts from within the data. With use of analytic techniques, researchers strive to explain the findings; questions are asked to tease out different levels of meaning, identify new concepts and themes, and permit a deeper interpretation and understanding. Orthopaedic practitioners should consider the use of qualitative research as a tool for exploring the meaning and complexities behind some of the perplexing phenomena that they observe in research findings and clinical practice.
How many interviews are enough?: an experiment with data saturation and variability
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